Selfishness at the Microscope: Your Diagnosis or Your Life

Thank you,
Richard [Ralston], for inviting me to speak at this forum; it is an honor for
me to address colleagues on such an important matter, one that affects me
daily, and, as a consequence, my patients.

I am a
diagnostician; I evaluate biopsies and excisions of skin by means of a
microscope and my mind. My goal is to
identify the nature of disease by evaluating the structure, or morphology, of
each lesion.

By its
nature, a diagnosis is the selfish concern of the diagnostician; he must focus
on every relevant fact of the case, the clinical diagnosis, the historical
precedents in the literature, his own experience, and all opposing viewpoints –
all for the purpose of telling the patient, usually the clinician in my case, that
the lesion is a benign neoplasm (for instance, a melanocytic nevus) or a
malignant one (a melanoma), or in some cases, one doesn’t know for sure, but
the facts favor one or the other diagnosis.

Why is this
process selfish? It is because the
diagnostician must look outward at the
facts, but turn inward to his own
mind, relying on his own judgment, taking the responsibility for the patient’s
life. Yes, he may be able to consult
others on a difficult case, but this is just an extension of fact
gathering. Ultimately, he must decide in
the privacy of his own soul.

Considering
how important it is for a diagnostician to be able to focus and concentrate on
the process of diagnosis, and considering what is at stake in every diagnosis –
life or death – he must be free to think, act, and be secure in his
relationship with the referring clinician and the patient so that, as much as
possible, the proper diagnosis is made and the proper action is taken. Most of us who perform this kind of work love
it; we love the challenge; we love being able to establish a diagnosis.

Yet, the
process of diagnosis cannot be touched in any fundamental way except to destroy
the conditions by which it functions optimally.

What are
those optimal conditions? There are
three that come to mind immediately, but perhaps there are more than these:

A
well prepared mind grounded in the liberal arts as well as the sciences

One’s
experience with the kinds of problems encountered routinely in one’s chosen
field and the ability to think beyond the routine so as to advance knowledge in
the field

Political
freedom, based on the principle of individual rights

The first
two parameters have been the time-honored mainstay of medical practice, at
least in the modern era of medicine from the 19th Century to the
1960’s. As a consequence, physicians as
diagnosticians have developed a strong sense of personal pride in their work,
wealth from a successful practice, and concern for the patient’s well being as
well as the patient’s privacy.

It is not true that physicians made themselves
wealthy by sacrificing their patients – far from it. Both
benefited. It was a trade relationship
in every way including when charity was extended to the indigent, especially prior to the Medicare & Medicaid era. During this period, for instance, the honest poor did not believe the care
they received was theirs by right, but by trade, if nothing more than by offering
a “thank you” for the care they received.
They understood on some level that skills of the type offered by
physicians were earned at a great price and neither could nor should be demanded of physicians without
some kind of mutually agreed exchange.

This changed
in the Medicare era, and it has become much worse since I entered the
profession in the 1980’s. There is today
no real trade relationship with patients free from intervention by the
government. The government has taken on
the role of the “grantor” of “charity”, but there is no trade in this because
the government has extorted physicians’ labor, regulated their practices, and
compromised their thinking by paying for their services with stolen money
redistributed to them via the Social Security Administration.

This brings
me to point three: Political Freedom in
the medical professions.

Let me be
frank; we are not living under political freedom in the practice of medicine,
which will not shock most of you. Here
are some examples:

Our
prices are fixed by Medicare, and Medicare drives the pricing in what remains
of the insurance industry, the latter being blamed for all the economic ills
they did not cause in any fundamental way.

Our
industry is regulated beyond belief. The
FDA, licensing laws (both federal and state), and arbitrary recertification
laws are just a few of them.

In
pathology laboratories, endless checklists must be maintained with the specter
of arbitrary inspection and the threat of license revocation, even when
laboratories are reputable and have never been sued for violating anyone’s
rights.

Private
research is more difficult to do because so much money is funneled by the
government into publically funded research, often with laughable consequences,
if they were not so serious.

What may shock you, however, is that there is
resistance to political freedom in
the medical profession by the physicians themselves, with notable exceptions. In my sphere in St. Louis, I have observed
very little actual opposition to huge bureaucracies, such as the FDA, Medicare,
Medicaid, the National Institutes of Health, the “bricks and mortar VA”, or the
CDC. Most physicians want them. I do not; I believe they exist because of the
immoral principle of altruism. Even if
one did not consider the individual rights infringements involved with these
institutions, at their very best they
are too expensive, too bureaucratic, and they don’t deliver what they claim to
deliver.

The title of
this talk is “Selfishness at the Microscope:
Your Diagnosis or Your Life.” We
are approaching a point in the discipline of medicine where it is becoming more
difficult to practice the art of diagnosis.
When private practice ceases to exist, there will be checklists of
prescribed criteria that must be met by government edict to “establish” an “official”
or government sanctioned diagnosis so that it will be covered by the governmental
system. Even if a few of us private
practitioners remain to weather this storm on our rights, our numbers will be
diminished because of the difficulty coping psychologically with being told what
we must do, rather than by
controlling the terms of our own practices and doing what we should do for ourselves and our patients. If this happens, diagnosticians like me will
be out of the system because personal profit in medicine will no longer be allowed.

Let there be
no mistake about the meaning of profit; it is the payment on the risk taken for
creating the values necessary to sustain life and make it worth living; profit
is morally good and necessary. If profit becomes illegal, your life will be at serious risk
because all diagnoses will be political rather than based on facts evaluated by
a free and independent mind.

Don’t let
that happen. Oppose government regulated
and controlled medicine in any legal way you can, and reverse it to a completely
private system when the next opportunity is open. As long as men are semi-free, the opportunity
will be open.

Jefferson,
his 1st Inaugural Address, in this city, March 4, 1801, stated that:

... fellow-citizens—a wise and frugal Government, which shall
restrain men from injuring one another, shall leave them otherwise free to
regulate their own pursuits of industry and improvement, and shall not take
from the mouth of labor the bread it has earned. This is the sum of good government, and this
is necessary to close the circle of our felicities.

Ayn Rand,
the philosopher, in her 1963 article on “Man’s Rights” (1) stated also that:

There is no such thing as “a right to a job” — there is only
the right of free trade, that is: a
man’s right to take a job if another man chooses to hire him. There is no “right to a home,” only the right
of free trade: the right to build a home
or to buy it. There are no “rights to a
‘fair’ wage or a ‘fair’ price” if no one chooses to pay it, to hire a man or to
buy his product. There are no “rights of
consumers” to milk, shoes, movies or champagne if no producers choose to
manufacture such items (there is only the right to manufacture them oneself). There are no “rights” of special groups, there
are no “rights of farmers, of workers, of businessmen, of employees, of
employers, of the old, of the young, of the unborn.” There are only the Rights of Man — rights possessed by every individual man and by all men as individuals.

In closing,
and in this same vein, there is no right to health care except by producing it
or trading for it, else it will cease to exist – and so will your diagnosis. Without your rights secured, your diagnosis
will matter no longer – because it will not be
a diagnosis.

If your
diagnosis is at stake, then your life
is at stake as well as the lives of every individual you love. If you care about your diagnosis, then don’t
allow the Rights of Man to be infringed
further without a fight.

If you wish
to live as a human being, then help return the practice of medicine to the private practice of medicine.